Global Burden of Cancer

For many years, global health has been associated with diseases like HIV/AIDS and malaria. And rightly so. These diseases present significant threats to health around the world. But they aren't the only major killers. In fact, they're not even the leading killers anymore! Today, cancer claims more lives globally than HIV/AIDS, malaria, and tuberculosis combined, and the death toll from cancer is only going to grow.

Cancer is a major burden of disease worldwide. Each year, tens of millions of people are diagnosed with cancer around the world, and more than half of the patients eventually die from it. In many countries, cancer ranks the second most common cause of death following cardiovascular diseases.

The axillary surgery causes the bulk of postoperative discomfort for breast cancer patients, and minor complications are frequent. Seromas are frequently seen, especially if the drain is removed early. These can be managed by aspiration in the outpatient clinic. In the long term, numbness in the medial aspect of the arm is universal if the intercostobrachial nerve has been divided.

Lymphedema and recurrent cellulitis are the most feared and potentially disabling of the complications. The reported incidence of lymphedema varies from 7-60% according to the methods used to assess the arm and the interval between surgery and follow-up. Many recent studies have reported a 15-20% incidence after treatment with axillary dissection or axillary irradiation. The incidence is much higher if both surgery and radiation therapy are used.

The extent of axillary surgery and the use of axillary radiation therapy are the only factors that have been consistently associated with the formation of lymphedema. Older age, obesity and infection are other likely risk factors.

Lymphedema can appear years after the surgery. It is routine to advise patients to avoid arm swelling and infection by taking special care not to suffer cuts and scrapes on the operated side, to avoid injections, blood-pressure monitoring, and blood draws, to avoid constricting clothing and jewelry, etc.

Warmuth reported a survey of 330 patients who were disease-free 2-5 years after surgery for early-stage breast cancer. Thirty-five percent reported numbness, 30% reported pain, 15% reported arm swelling, and 8% reported limitation of arm movement. Most of the symptoms were mild and did not interfere significantly with daily activity.

Fig. 7.11. Axillary dissection in progress. The anterior tributary of the axillary vein has been divided, the intercostobrachial nerve has been preserved and the long thoracic nerve identified.

Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.This is the first report of the major North American trial of breast-conservation therapy from the NSABP.

Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.This is a review of all aspects of breast-conservation therapy.

Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease.

Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy.

Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.This report gives a good idea of the range of complications after axillary dissection.

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